Amir Qaseem, MD, PhD, MHA; Stephan D. Fihn, MD, MPH; Sankey Williams, MD; Paul Dallas, MD; Douglas K. Owens, MD, MS; Paul Shekelle, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians*
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Potential Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved according to ACP's conflicts of interest policy. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm. Author and peer reviewer disclosure information for the multisocietal stable IHD guideline, on which these guidelines are based, may be found in the published multisocietal document (2). Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1769.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Fihn: 1100 Olive Way, Seattle, WA 98101
Dr. Williams: 423 Guardian Drive, Philadelphia, PA 19104.
Dr. Dallas: 1906 Bellview Avenue, Roanoke, VA 24014.
Dr. Owens: 117 Encina Commons, Stanford, CA 94305.
Dr. Shekelle: 11301 Wiltshire Boulevard, Los Angeles, CA 90073.
Author Contributions: Conception and design: A. Qaseem, S.D. Fihn, D.K. Owens, P. Shekelle.
Analysis and interpretation of the data: A. Qaseem, S.D. Fihn, S. Williams, P. Dallas, D.K. Owens.
Drafting of the article: A. Qaseem, S.D. Fihn, S. Williams, P. Dallas, D.K. Owens.
Critical revision of the article for important intellectual content: A. Qaseem, S.D. Fihn, S. Williams, P. Dallas, D.K. Owens, P. Shekelle.
Final approval of the article: A. Qaseem, S.D. Fihn, S. Williams, D.K. Owens, P. Shekelle.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem.
Collection and assembly of data: A. Qaseem, S.D. Fihn.
The American College of Physicians (ACP) developed this guideline in collaboration with the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, and Society of Thoracic Surgeons to help clinicians diagnose known or suspected stable ischemic heart disease.
Literature on this topic published before November 2011 was identified by using MEDLINE, Embase, Cochrane CENTRAL, PsychINFO, AMED, and SCOPUS. Searches were limited to human studies published in English. This guideline grades the evidence and recommendations according to a translation of the ACCF/AHA grading system into ACP's clinical practice guidelines grading system.
This guideline includes 28 recommendations that address the following issues: the initial diagnosis of the patient who might have stable ischemic heart disease, cardiac stress testing to assess the risk for death or myocardial infarction in patients diagnosed with stable ischemic heart disease, and coronary angiography for risk assessment.
The American College of Physicians' Guideline Grading System
Comparison of Grading Systems From the ACP and ACCF/AHA
Diagnosis of patients suspected of having ischemic heart disease.
CCTA = computed coronary tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; echo = echocardiography; IHD = ischemic heart disease; MPI = myocardial perfusion imaging; UA = unstable angina; UA/NSTEMI = unstable angina/non–ST-segment elevation myocardial infarction.
* See Table 2 of reference 2 for short-term risk of death or nonfatal myocardial infarction in patients with UA/NSTEMI.
† CCTA is reasonable only for patients with intermediate probability of IHD.
Risk assessment of patients with stable ischemic heart disease.
CCTA = coronary computed tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; echo = electrocardiography; LBBB = left bundle branch block; MPI = myocardial perfusion imaging.
Appendix Table 1.
Clinical Classification of Chest Pain
Appendix Table 2.
Short-Term Risk for Death or Nonfatal Myocardial Infarction in Patients With Unstable Angina
Appendix Table 3.
Alternative Diagnoses to Angina for Patients With Chest Pain
Appendix Table 4.
Pretest Likelihood of Coronary Artery Disease in Symptomatic Patients According to Age and Sex
Appendix Table 5.
Comparing Pretest Likelihoods of Coronary Artery Disease in Low-Risk Symptomatic Patients and High-Risk Symptomatic Patients
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Qaseem A, Fihn SD, Williams S, Dallas P, Owens DK, Shekelle P, et al. Diagnosis of Stable Ischemic Heart Disease: Summary of a Clinical Practice Guideline From the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157:729-734. doi: 10.7326/0003-4819-157-10-201211200-00010
Download citation file:
Published: Ann Intern Med. 2012;157(10):729-734.
Cardiac Diagnosis and Imaging, Cardiology, Coronary Heart Disease, Guidelines.
Results provided by:
Copyright © 2017 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only